Initial Resuscitation for Acute Kidney Injury in Cirrhosis

Massachusetts General Hospital50 enrolled

Overview

The goal of this interventional study is to evaluate two strategies for how to provide intravenous (IV) fluids for treating patients with acute kidney injury (AKI) in cirrhosis. The main question it aims to answer is: what is the safety, efficacy, and feasibility of providing a recommendation to use a Volume Assessment Guidance Algorithm (VAGA) or give standard of care doses of IV albumin? Patients will be randomly assigned where their treating teams will receive a VAGA-based recommendation or a standard of care IV albumin recommendation.

This randomized, open-label, pilot feasibility trial will assess a volume assessment guidance algorithm (VAGA) in patients with AKI and cirrhosis. Eligible patients must have AKI and decompensated cirrhosis. In addition to assessing the adherence to the suggested guidance, this study will measure the effect of the study intervention on grams of albumin given, clinical efficacy outcomes (AKI response rates, survival, RRT status, transplant status), and safety. Patients who meet eligibility criteria will be randomized 1:1 where the treating clinicians will receive a one-time recommendation for volume resuscitation using the VAGA or standard of care IV albumin repletion (1 g/kg/day for two days). Both groups will be followed with assessments at 48 hours after randomization, hospital discharge, and 90-days after randomization. The primary efficacy outcome, grams of albumin, will be measured at 48 hours after randomization. Primary secondary efficacy outcomes (grams of albumin, AKI response) will be assessed at time of hospital discharge. If a patient undergoes liver transplantation or initiation of RRT during the admission, this will serve as a censoring date for these outcomes, and relevant data will be collected at the time of the first of these events. The primary feasibility outcome is adherence to the suggested guidance, assessed at 48 hours after randomization. The VAGA group will receive one of three potential clinical recommendations: (a) no further volume resuscitation, (b) resuscitation with crystalloid, or (c) resuscitation with colloid. This study will prospectively enroll approximately 50 adult patients at a single center.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

Interventions

Recommendation: No Further ResuscitationOTHER

Treatment teams are encouraged not to administer any additional fluids

Recommendation: Resuscitation with CrystalloidOTHER

Treatment teams are encouraged to administer crystalloid. Amount of resuscitative fluid will be determined by treatment team's clinical assessments and usual standards of care

Recommendation: Resuscitation with ColloidOTHER

Treatment teams are encouraged to administer colloid. Amount of resuscitative fluid will be determined by treatment team's clinical assessments and usual standards of care

Recommendation: Standard of Care IV AlbuminOTHER

Treatment teams are encouraged to administer 1 g/kg/d IV albumin (maximum 100 g/day) over 2 days

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Adult age 18 years or greater 2. Signed informed consent form (ICF) by any subject capable of giving consent, or, when the subject is not capable of giving consent, by their legally authorized representatives prior to initiation of any study procedures. 3. Admitted to the hospital 4. Diagnosis of decompensated cirrhosis (either prior to admission or new diagnosis on admission). 5. Presence of acute kidney injury (AKI) as defined by International Club of Ascites (ICA) criteria, defined as SCr increase of ≥0.3 mg/dL within 48 hours or ≥50% increase from baseline which is known or presumed to have occurred within the prior 7 days. Exclusion Criteria: 1. Requiring \>2 liters (L) supplemental oxygen at the time of screening. 2. In shock requiring vasopressors (vasoconstrictors for the treatment of AKI such as terlipressin, midodrine, and octreotide are allowed). 3. Allergy or other contraindication to IV albumin administration. 4. Death, liver transplant, or renal replacement therapy (RRT) expected within 48 hours. 5. Patient and/or legally authorized representative unable to provide informed consent. 6. Hepatic encephalopathy grade 3 or 4 at the time of screening. 7. Already received \>200 g albumin during admission at the time of screening. 8. Severe, active bleeding requiring 3 or more units of red blood cell transfusion in the 48 hours prior to screening. 9. Admission to the intensive care unit at the time of screening. 10. Mechanical ventilation at the time of screening. 11. Presence of New York Heart Association (NYHA) class 3-4 symptoms of congestive heart failure at the time of screening. 12. History of prior liver or kidney transplant. 13. Pregnant or nursing status 14. Any condition, in the opinion of the investigator, that could confound or interfere with the safe completion of study activities.

Outcomes

Primary Outcomes

IV albumin received (grams)

Time frame: From date of randomization up to 48 hours

Adherence to suggested guidance

For the VAGA group, adherence is defined as: No further resuscitation (\<500 mL total volume of IV fluid given), Resuscitation with crystalloid (\>500 mL total IV fluid given, with \<50 g IV albumin and ≤2 units blood), Resuscitation with colloid (≥50 g IV albumin or ≥2 units blood given). For the Standard of Care group, adherence is defined as receiving within 20% of the suggested IV albumin dose in grams.

Time frame: From date of randomization up to 48 hours

Incidence of treatment-emergent adverse events and serious adverse events

Time frame: From date of randomization up to hospital discharge, assessed up to 90 days

Secondary Outcomes

IV albumin received (grams)

Time frame: From date of hospital admission up to hospital discharge, or the date of time of initiation of renal replacement therapy or liver transplant, whichever came first, assessed up to 90 days.

AKI Response

AKI response is defined as complete response (return of serum creatinine to a value within 0.3 mg/dL of the baseline value), partial response (regression of AKI stage with a reduction of serum creatinine (SCr) to ≥0.3 mg/dl above the baseline value), or no response (neither complete or partial response met).

Time frame: From date of randomization up to hospital discharge, or the date of time of initiation of renal replacement therapy or liver transplant, whichever came first, assessed up to 90 days.

Vital Status

Alive or dead

Time frame: From date of randomization up to 90 days

Renal Replacement Therapy Initiation

Yes or No

Time frame: From date of randomization up to 90 days

Liver transplant

Yes or No

Time frame: From date of randomization up to 90 days

Initial Resuscitation for Acute Kidney Injury in Cirrhosis

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes